SMC ruling has doctors questioning middlemen’s new fees structures

Reshmin Kaur Cheema, 19 Jun 2017

SMC's new ethics code and guidelines for doctors: TPA fees “must not be based primarily on the services you provide or the fees you collect”.

Third-party administrators (TPAs) are hurriedly trying to meet the 1 July deadline to produce a new fee structure in line with the recent ruling by Singapore Medical Council (SMC), whereby clinicians must only pay fees that reflect the TPA's work.

At the moment, middlemen, who usually consist of insurers or employers who pay for the patient's treatment, take a percentage of the medical bill as their fee.

However, the SMC's new ethics code and guidelines for doctors states that “such fees must not be based primarily on the services you provide or the fees you collect”. This, generally mean that this concept will be eliminated.

Doctors have been given time to cut ties or modify arrangements

The SMC’s updated code and guidelines came into effect at the start of 2017 and a six-month extension was given for this implementation. Doctors have sufficient time to get out of their agreements and for TPAs to alter their charging methods.

Recent weeks have seen most TPAs sending doctors their new fee schedules. Some schemes that clinicians aware of are such as implementing fixed fees for different things like consultation and medicine.

Some TPA arrangements also charge fees that vary, depending on how comprehensive the information provided by the doctors is.

For instance, those requiring to-ing and fro-ing will be charged more. Middlemen are also adjusting their fee structure according to several tiers of fixed fees based on total bill or the nature of treatment or a combination.

Different TPAs with varying schemes

Middlemen like Fullerton Health said it will impose a fee ranging from SGD1.50 to SGD12 for a GP and SGD11.50 to SGD60 for specialist outpatient consultation.

On the other hand, MHC charges different fees for consultation, procedure, tests and medications. Consultation fees here can range from SGD1.95 at a clinic to SGD18 for a first specialist consultation.

Alliance Medinet has implemented a tiered charge system for GPs ranging from SGD1.90 to SGD32.80 for bills over SGD8. An example of this would be the fee for bills between SGD26.01 and SGD45 is SGD5.50.

One doctor commented on this system saying that those who charge the lesser amount will end up paying Alliance Medinet a larger portion of the bill. This, in turn, might get clinicians to increase their bills maximally, increasing healthcare overall.

Inpatient operation fees range between SGD20 to SGD180 and MHC is at the lower end of the spectrum. Parkway Shenton's iXchange is charging from SGD100 to SGD1,000. Their representative commented saying its fees was for the combined charges for the surgeon and anaesthetist.

Doctors are waiting to see if the SMC penalises anyone

Some doctors like gastroenterologist Desmond Wai have decided to opt out of this system. He did so as he “didn't want to take the risk”.

Should he be questioned by the SMC, he claimed that he would find it hard to explain why the fee he pays out can differ by hundreds of dollars, when each TPA is carrying out the same work.

The various fee tiers, he said, indicate “I'm still reimbursing the TPA according to what I do and charge”.

Wai decided “to opt out first and see what SMC does” because only a minor part of his business comes from TPAs. He would go back to the middlemen if the SMC accepts the new charges and does not take action against any clinician.

One TPA is charging a fee that is up to 5.5 times what another player is billing for some surgical procedures. “It makes it hard to believe that (the TPA’s) fee is based entirely on the work done (in) processing a claim,” said one surgeon.

“Some fees amount to 25% of what the doctor bills the patient, which is “quite aggressive”,” he added.

Some doctors are sticking with TPAs as business they get from them accounts for over 50% of their patients. They believe that because numerous doctors are still on such fee structures, it is not likely that the SMC will come after them all.

One doctor commented on this change saying, “The best scheme is if the doctor wins, the patient wins, and the TPA wins… TPAs are an integral part of our healthcare system to manage costs for companies and, the economy being in its current state, we definitely want to be able to support them if they’re fair to doctors.” MIMS

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